crit care in the trauma bay -...
TRANSCRIPT
Crit Carein The
Trauma Bay
Everything I do is Off-Label!
ATLS
ATLS
Case
Hypotensivein theField
HR 96BP 180/20
Sat 89% NCRR 22
GCS 14 (-1 Eyes)Moves Ext x 4
What doyou think?
IgnoreHR
Resuscitation. 2010 Sep;81(9):1142; Resuscitation
2011;82:556; J Trauma 2009;67:1051; BMJ 2004;328:451; J
Accid Emerg Med 1995;12:1; J Am Coll Surg 2003;196:679; J
Trauma 1998;45:534; J Trauma. 2011;71: 789–792
Low or normal HRs are not on their own
reassuring in sick trauma pts @emcrit
Ignore InitialAutomated BPs
J Trauma.
2003;55:860 –863
RepTime
Don’t believe the 1st
few BPs in sick trauma patients;
check your rep time@emcrit
So, if you can’ttrust the initial
vitals…
ETCO2
Low=Badness
<C>ABC
Push on BellySqueeze Pelvis
Feel Feet
Pelvis MovesUnder Your Hands
Bind It!
Better thanExFix
JACS 2007;204:935
Is Sheetingas Good?
Can youMake Things
Worse?
Pelvic Binding: Early and Often @emcrit
50/30
CavitiesMass Trans
AirwayMonitoring
Cavities:Where’s That
Bleed
ChestIntra-PRetro-PThighStreet
ChestIntra-P
Retro-PThighStreet
EmpiricChest Tubes
FingerThoracostomy
200 ml Blood on LNothing on R
CT on Left
ChestIntra-P
Retro-PThighStreet
FAST
Liver Tipwith Patient inTrendelenberg
When the FAST really matters, RUQ Liver
tip with Trend. is the money! @emcrit
ChestIntra-P
Retro-PThighStreet
CavitiesMass Trans
AirwayMonitoring
Mass Trans:Hemostatic Resus
PRBC/Clotting Factors
1:1vs.1:2
PROPPR Trial
Should be in the Trauma Bay
Type O PRBCThawed AB Plasma
Scores
>4 Units in the1st Hour
LLS Score
TXA
EarlyCryo
The Riseof the
Concentrates
FluidChoices in
Sick TraumaPatients
Warm
Under Pressure
Calcium
90/50after
2 PRBC2 FFP
CavitiesMass Trans
AirwayMonitoring
MEDs:Ketamine
Rocuronium
Hypotensive intubation meds:
high-dose roc, low-dose ketamine.
@emcrit
Sat 84%with AirQ ILA
Cric
ScalpelFingerBougie
The safest way to cricis with a finger and a
bougie! @emcrit
CavitiesMass Trans
AirwayMonitoring
FemoralArterial Line
Shock 40(6), December
2013, p 527–531
Ultrasound
CFA notthe SFA
Yes, it’s okin a pelvic fx
MAP 48
ResusGoal?
PermissiveHypotension?
MinimalNormotension
BP is kind of meaningless;we care about
perfusion
J Trauma 2014;41-Supp. 1:21
J Trauma 2014;41-Supp. 1:21
All with MAP of 65
Normal Septic Trauma Trauma
All with MAP of 65
Trauma Trauma
May be 50very soon
J Trauma 2011;70:652
50 vs 65
MAP >=
65and perfusing
<65give the fluid of
trauma
>65eat away at the
adrenals
Fentanyl50-100mcg
J Trauma. 2002
Jun;52(6):1141-6
At 1 mgpt is warm, perfusing &anesthetized
What aboutTBI?
Some would saySBP>90
We have a bedsidetest for
Increased ICP
Ocular ultrasound is a bedside test for ICP elevations in trauma
patients. @emcrit
90/506 PRBC4 FFP
1 Pack Plt1 Pack Cryo
Where should we go now?
ORvs.IR
WeShouldn’tHave to
Choose
Resuscitation with Angiography, Percutaneous Techniques and OperativeRepair
Can J Surg. Oct 2011;
54(5): E3–E4.
RAPTOR: we should not have to choose
between IR and OR. @emcrit
40/20
60/40
BedsideIntervention?
REBOA
ResuscitativeEndovascular BalloonOcclusion of theAorta
From Megan Brenner
REBOA: vascular control without the
big cut—coming to a trauma center near
you. @emcrit
120/80More fentanyl andto RAPTOR Suite
for Angio
Review
Low or normal HRs are not on their own
reassuring in sick trauma pts @emcrit
Don’t believe the 1st
few BPs in sick trauma patients;
check your rep time@emcrit
Pelvic Binding: Early and Often @emcrit
When the FAST really matters, RUQ Liver
tip with Trend. is the money! @emcrit
Hypotensive intubation meds:
high-dose roc, low-dose ketamine.
@emcrit
The safest way to cricis with a finger and a
bougie! @emcrit
Ocular ultrasound is a bedside test for ICP elevations in trauma
patients. @emcrit
RAPTOR: we should not have to choose
between IR and OR. @emcrit
REBOA: vascular control without the
big cut—coming to a trauma center near
you. @emcrit
